Pranee Liamputtong (ed.)Women, Motherhood and Living with HIV/AIDS2013A Cross-Cultural Perspective10.1007/978-94-007-5887-2_19© Springer Science+Business Media Dordrecht 2013
19. Coping with Patriarchy and HIV/AIDS: Female Sexism in Infant Feeding Counseling in Southern Africa
(1)
Research for the Future, 170, Elgin, 7180, South Africa
Abstract
In an ethnographic study focusing on infant feeding counseling in southern Africa conducted in the period 2003–2006, mothers complained of feeling judged, shamed, and stigmatized by their female counselors. Female counselors confirmed that they revert at times to confronting and shaming mothers. We postulate the hypothesis that this behavior of shaming and judging can be understood as female sexism; it finds its rationality within the internalized gender dynamics of a highly sexist society, further polarized by the moral stigma of AIDS. We found the underlying dynamic to be judgmental distancing, which can be understood as a psychological defense mechanism; it enables the counselors to avoid looking in the mirror of the self that they see reflected in their female clients. Judging the mothers as individuals for the predicament they find themselves in provides the counselors with a subconscious buffer that protects them from the reminder that they themselves share a similar risk. Counselors’ evasion and denial of their own and of their clients’ feelings and situations subvert however the purpose of the counseling and risk further stigmatizing or re-traumatizing HIV-positive mothers. Defensive distancing also predisposes counselors to the mental health hazards of compassion fatigue and the syndrome of vicarious traumatization. Yet, those counselors who seek support to help them face their emotions or reactions are unlikely to find it. The reality of patriarchy, impacting as female sexism on the relationship between counselor and mother, is not sufficiently appreciated by the health services yet. To realize therefore the dream of an AIDS-free generation, counselors in southern Africa need better training and ongoing support that is grounded in gender awareness. The precondition is that health researchers, policy makers, and managers acknowledge the patriarchal realities in which mothers and counselors live, the existence of female sexism in the counseling relationship, and the dysfunctional counseling which results from this. Failing to acknowledge these dynamics exposes both mothers and counselors to risks which are harmful to them as human beings and which the region in its fight against HIV/AIDS can ill afford.
Dr Alan Jaffe passed away in 2009.
1 Introduction
HIV-positive mothers in resource-poor settings in developing countries are faced with an appalling choice, between considerable risk of postnatal mother-to-child transmission (MTCT) of HIV through breastfeeding and considerable risk from infectious disease and malnutrition to these infants from not breastfeeding (WHO 2000). Policy makers have been given hope by studies that indicate that infants who are exclusively breastfed have a risk of being HIV-infected that is manyfold lower than those who are partially breastfed or receive mixed feeding (Coovadia et al. 2007). The availability of antiretroviral treatment (ART), also in highly active (HAART) combinations, holds potential both as treatment and as prophylaxis by lowering viral loads in breast milk (Arendt et al. 2007; Kilewo et al. 2007). Together, these strategies promise to revive the dream of an AIDS-free generation in southern Africa. See also Chaps. 9, 10, and 16 in this volume.
Yet, caution has to be expressed in making HAART the panacea of preventing MTCT (PMTCT); the dispensing of the drugs takes place within the PMTCT counselor-client relationship, and the challenges of adherence and the risks of toxicity and resistance make the effectiveness of HAART dependent on the quality of the counseling encounter. Research has indicated that these encounters have significant weaknesses (Chopra et al. 2005), disappointing impact (Rollins et al. 2006), and are fraught with problems (Buskens and Jaffe 2008).
PMTCT counseling is drawn into a medico-moral discourse that emphasizes the values of chastity and fidelity, predominantly for women; patriarchy exalts motherhood and male sexuality, while regarding female sexuality with contempt (Seidel 1993). Because of the association of HIV/AIDS as a sexual and immoral disease, HIV-positive pregnant women carry a threefold burden of stigma: as women, as HIV-positive women, and as HIV-positive women who are presumed to have allowed themselves to fall pregnant (Panos Report 2001). This triple stigma casts HIV-positive women and mothers as sexually immoral, even when they would be married, have been faithful to their (often polygamous) partner and, most probably, would have been exposed to the disease through their partner (see also Chap. 15 in this volume). At the same time, the public health agenda has framed antenatal care as an opportune moment for monitoring and intervening to control the HIV epidemic. This implies that the persons who would be least positioned to bring the message of HIV infection into their families will be these women and that at a time when they are least equipped psychologically to face such a challenge because of pregnancy and breastfeeding. Furthermore, what is required for an HIV-positive pregnant woman or feeding mother to prevent vertical transmission – disclosure, negotiating safe sex with male partners, and engaging infant feeding that is exclusive of water, medicine, and solids – are profound behavior changes for them, their partners, and their families. This set of behavior changes is a challenge to the identity of the “decent” woman who respects her partner, family, and community, as it requires that she challenge traditional systems of belief, influence, and authority (Buskens et al. 2007a).
This chapter examines to what extent the infant feeding (IF) counselor-client interaction is capable of meeting current and future health expectations and requirements, including those of ART and HAART, by focusing on the nature of the interpersonal dynamics between the IF counselors and their clients during the counseling encounter.
2 The Study
The research on which this chapter is based consisted of ethnographic fieldwork done over a period of 7 months in 2003 across 11 sites in 3 southern African countries: Namibia, Swaziland, and South Africa. Sites were selected to include a range of settings (urban, peri-urban, and rural; formal, traditional, and informal settlements) to facilitate the development of a cross-sectional analysis of infant feeding practises in the region (Bechhofer and Paterson 2000). Researchers were female indigenous language speakers trained in the use of participant observation, observations, formal and informal interviews, and focus groups. Primary research respondents were pregnant women and mothers with infants of up to a year old (jointly termed “mothers” in this chapter). A total of 11 pregnant women, 167 mothers of infants, 32 relatives (fathers, grandmothers, and caregivers), 22 health workers (nurses, counselors, PMTCT co-coordinators, and a doctor), and 7 traditional healers were formally interviewed. The interviews were transcribed and translated. The data comprised field notes, reflective diaries, informal interview notes, and formal interview transcriptions. Data analysis was done in 2004 using internal and external analysts. First, the researchers analyzed their own data using the initial steps of a conceptual framework analysis designed for health policy research (Ritchie and Spencer 1994). Then, the principal researchers and an external analyst analyzed the total data set independent of each other. Finally, the principal investigator applied “analytic retroduction,” a double-fitting of analysis and data collection (Ragin 1994). This is a refinement of a general “inductive” approach widely used to allow themes to emerge from qualitative data (Thomas 2006).
3 Mothers and Female Health Workers: A Troubled Relationship
An evaluation of HIV/AIDS counseling in South Africa found that counselors were disadvantaged as role models because just like their clients, they would tend to be in relationships that would inhibit safe sex practices. This would create incongruence with the health messages they would be giving (Richter et al. 1999).
A semiotic analysis was conducted on ethnographic interviews with obstetric nurses involved directly or indirectly with infant feeding and counseling in South Africa. This analysis found that obstetric nurses judge, “otherize,” and marginalize young female clients as if their welfare was not a legitimate concern for these nurses. Health care workers were found to judge – sometimes even harshly – vulnerable and unmarried mothers, regardless of their HIV status. Seidel (1993) notes how nurses’ perceptions of these women as shaped by a “medico-moral discourse” which gives positive value to “compliance” rather than to individual rights. This would explain why some nurses would not see their role as supporting vulnerable patients but as needing to tell them how to behave (Seidel 2000).
Our findings on the counseling encounter were previously reported in an article from this same study (Buskens and Jaffe 2008). In summary, most infant feeding encounters were found to be discordant, with both parties talking past one another; two opposing subtexts inform counselors’ and mothers’ perspectives, attitudes, and behaviors. Mothers were seeking counsel from the “consultation,” yet counselors confronted clients with their risks, so as to persuade them to “correct” their behavior. Mothers reported feelings of being judged, stigmatized, and shamed; counselors confirmed that they revert at times to “confronting, judging, and shaming mothers.” To avoid these feelings, mothers admit to telling nurses what they think the nurses want to hear. Counseling nurses complained of feelings of frustration and anger that women clients would neither tell them the truth about their infant feeding habits nor heed their best advice. Many counselors were noted to suffer from stress, depression, and burnout. Counselors were seldom able to create an environment where choice became an option for the mothers.
While the IF counseling literature mentioned thus far makes note of the troubled nature of the IF counseling encounter and its inability to deliver what is expected, the authors found a dearth of in-depth analysis. It was therefore deemed necessary to spread the net wider; hence, we include here research into other health and caring relationships in southern Africa that made mention of similar health worker attitudes.
A study on TB in South Africa found that nurses’ recognition of excessive identification with their patients tends to trigger strategies of distancing and judgment, causing them to hide behind a mask of defensive coping mechanisms when nurses identified “too close for comfort” with patients sharing the same ethnicity (Van der Walt 2002). The authors explain that nurses’ anxiety has its roots in incongruous roles: epidemic infection control (including quarantine) versus caring for patients (and their rights, e.g., to access and free movement). Where nurses share ethnicity, there may be further fears of psychological contamination, as if their shared history might rub off and negate nurses’ social gains: “the professional role may represent a way for nurses to advance socio-economically… the implicit threat (is) of never being able to get away” (Van der Walt and Swartz 2002: 1007; Van der Walt 2002). Nurses tend to take refuge against this “emotional invasion” of ethnic contamination by hiding behind a “mask” of roles and routines: the uniform, epaulettes, and stethoscope help to shield her behind a professional status; tasks shield her from the total reality. According to Van der Walt and Swartz (2002: 1006), “it is safer for the nurse to acknowledge the control of the disease and the bacteria than to open themselves up to the illness experience and the human needs of the person.” The authors quote extensively from their earlier article (Van der Walt and Swartz 1999) on the work of the psychoanalyst Menzies-Lyth and how psychological defense mechanisms are integrated into institutional and organizational culture and how these manifest as rigid routines and procedures to protect nurses against “emotional contagion” (Menzies-Lyth 1960).
An earlier South African study had reported extraordinarily incongruous carer behavior in obstetric services, taking the form of clinical neglect, verbal abuse, and physical abuse; this was interpreted as a need from the nurses to assert control over an often unpredictable environment and challenges to their status, power, and authority. Nurses deployed coercion and violence as a means of creating “social distance” in a struggle to assert fantasies of professional and moral superiority and their middle-class aspirations and identity (Jewkes et al. 1998).
Anecdotal evidence from across southern Africa has confirmed incidences of abuse and troubled nurse-patient relationships. Reports that emanated from maternity wards in Swaziland revealed that pregnant women preferred to be delivered by male midwives because they found the males to be more gentle and compassionate with them.1
In our study, mothers have been reporting on clinical encounters with midwives and nurses in obstetric wards and clinics – maternity, antenatal, and postnatal. Obstetric services provide the physical setting and the professional context for infant feeding counseling encounters. Furthermore, clinical practise is part of the psychological context for infant feeding counselors who are nurses (or in the case of South Africa, lay counselors who were previously nurses).
3.1 “They Run Away”
We found that most counseling sessions were combined with maternal VCT, with clients being expected to make an infant feeding decision while they are still reeling, in emotional turmoil from the news of their HIV status. Counselors confirmed an exclusive focus on the health of the infant as the purpose of PMTCT:
They only speak about what you must do with the baby, and nothing is being said about you and how to cope with the news they just told you. I mean counseling you to understand about your status is the most important, but they run away from that. (34-year-old HIV-positive mother, Soweto)
3.2 “They Will Shout at You”
Although mothers agree that nurses are not all the same, many HIV-positive mothers report experiences of verbal abuse and belittling, in this case, with information that implicitly exposes their HIV status:
You know if you go to the clinic with a bottle, they will shout at you and say that you are lazy to breastfeed. What I don’t like about them saying that is they talk very loud so that everybody could hear. What for, we are all human, and we also need to be treated like everybody else, and they must remember that we are not children. (HIV-positive focus group participant, Soweto)
3.3 “Yah, You Know Your Disease”
Mothers reported numerous frank breaches of confidentiality within public contexts, often in ways that were unequivocally unkind and stigmatizing, if not cruel or brutal. In this quote, the nurse reveals also the baby’s HIV status, as well as the mothers CD 4 result, signifying late-stage disease: AIDS. This mother seems to cooperate reluctantly in this disclosure but explains her apparent collusion as mediated by her fear and dependence on the nurse for information:
The sister is just asking things on HIV in front of other people. When I went back for the baby’s results, the registered nurse asked me “You ought to know what your problem is.” (I answered) “Yes,” and the registered nurse asked me again “what type of disease.” I first kept quiet and later responded “AIDS.” There were many people. An older woman sat next to me when the nurse asked me all these questions. There is no privacy there, unlike the ANC (antenatal clinic). After asking these questions, the nurse told me, “yah you know your disease, the baby has it also, but it is not (the) worst.” She said something about 58. But I did not want to ask, as I feared that this sister will maybe not expla in nicely or she will just talk everything in front of the people. (26-year-old HIV-positive shack dweller and mother of two, Windhoek)Stay updated, free articles. Join our Telegram channel
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